10 octobre 2009
Collision de l'Hudson : la bande est released
Après une intervention de l'Associated Press auprès de la FAA au nom de la liberté de l'information, cette dernière a rendu publique la totalité de l'enregistrement audio de la tour de KTEB au moment de l'accident ... cela fait évidement couler encore beaucoup d'encre le l'autre coté de l'atlantique.
Cet enregistrement est accompagné du transcript officiel disponible lui aussi sur le site de la FAA.
21 août 2009
Collision de l'Hudson : controverse et lynchage médiatique
Aux USA, les média se déchainent en cette fin d'été à propos de la collision entre un avion de tourisme et un hélicoptère au dessus de l'Hudson.
Les faits rapportés par le NTSB
"On August 8, 2009, at 11:53 a.m. EDT, a Eurocopter AS 350 BA (N401LH) operated by Liberty Helicopters and a Piper PA-32R- 300 (N71MC) operated by a private pilot, collided in midair over the Hudson River near Hoboken, New Jersey. The certificated commercial pilot and five passengers onboard the helicopter were killed. The certificated private pilot and two passengers onboard the airplane were also killed. Visual meteorological conditions prevailed and no flight plans were filed for either flight.
The helicopter departed West 30th Street Heliport (JRA), New York, for a sightseeing tour at 11:52 a.m. The airplane departed Teterboro Airport (TEB), Teterboro, New Jersey, at 11:49 a.m.; destined for Ocean City Municipal Airport (26N), Ocean City, New Jersey. The airplane pilot requested an en route altitude of 3500 feet.
According to preliminary radar data, the helicopter turned south from JRA and climbed to 1,100 feet, with a transponder code of 1200. According to witnesses, the pilot of the helicopter had transmitted a position report of "Stevens Point" (Stevens Institute of Technology, Hoboken, New Jersey) on the common traffic advisory frequency (CTAF), 123.05.
On the day of the accident, Teterboro Air Traffic Control Tower staff consisted of five controllers. At the time of the accident, the tower was staffed with two controllers: one controller was working ground control, local control, and arrival radar, and was also acting as the controller in charge of the facility. The second controller was working the flight data/clearance delivery position. Two other controllers were on break and the front line manager had left the facility at about 1145.
At 1148:30, the Teterboro tower controller cleared the airplane for takeoff on frequency 119.50. The first radar target for the airplane was recorded at 1149:55 as the flight departed runway 19.
The tower controller advised the airplane and the pilot of another helicopter operating in the area of each other and instructed the pilot of the airplane to remain at or below 1,100 feet. At this time, the tower controller initiated a non-business-related phone call to Teterboro Airport Operations. The airplane flew southbound until the controller instructed its pilot to turn left to join the Hudson River. At 1152:20 the Teterboro controller instructed the pilot to contact Newark on a frequency of 127.85; the airplane reached the Hudson River just north of Hoboken about 40 seconds later. At that time there were several aircraft detected by radar in the area immediately ahead of the airplane, including the accident helicopter, all of which were potential traffic conflicts for the airplane. The Teterboro tower controller, who was engaged in a phone call at the time, did not advise the pilot of the potential traffic conflicts. The Newark tower controller observed air traffic over the Hudson River and called Teterboro to ask that the controller instruct the pilot of the airplane to turn toward the southwest to resolve the potential conflicts. The Teterboro controller then attempted to contact the airplane but the pilot did not respond. The collision occurred shortly thereafter. A review of recorded air traffic control communications showed that the pilot did not call Newark before the accident occurred.
The helicopter departed from the 30th Street Heliport at 1152 for what was planned to be a 12-minute tour. The initial part of the tour was to be flown outside class B airspace, so the pilot was not required to contact air traffic control before or after departure. The first radar target for the helicopter was detected by Newark radar at about 1152:27, when the helicopter was approximately mid- river west of the heliport and climbing through 400 feet. According to recorded radar data, the helicopter flew to the west side of the river, and then turned southbound to follow the Hudson. According to Liberty Helicopters management, this was the expected path for the tour flight. The helicopter continued climbing southbound until 1153:14, when it and the airplane collided at 1,100 feet.
As noted above, immediately after the Teterboro tower controller instructed the airplane to contact Newark tower on frequency 127.85, the Newark controller called the Teterboro controller to request that they turn the airplane to a heading of 220 degrees (southwest) and transfer communications on the aircraft. As the Newark controller was providing the suggested heading to the Teterboro controller, the pilot of the airplane was acknowledging the frequency change to the Teterboro controller. The Teterboro controller made two unsuccessful attempts to reach the pilot, with the second attempt occurring at 1152:50. At 1152:54, 20 seconds prior to the collision, the radar data processing system detected a conflict between the airplane and the helicopter, which set off aural alarms and a caused a "conflict alert" indication to appear on the radar displays at both Teterboro and Newark towers. During interviews both controllers stated that they did not recall seeing or hearing the conflict alert. At 1153:19, five seconds after the collision, the Teterboro controller contacted the Newark controller to ask about the airplane, and was told that the pilot had not called. There were no further air traffic control contacts with either aircraft. The role that air traffic control might have played in this accident will be determined by the NTSB as the investigation progresses. Any opinions rendered at this time are speculative and premature.
The recorded weather at TEB at 1151 was wind variable at 3 knots, visibility 10 miles, sky clear, temperature 24 degrees Celsius, dew point 7 degrees Celsius, altimeter 30.23 inches of mercury."
Le contrôleur en poste ainsi que son superviseur qui s'était absenté du bâtiment ont été immédiatement suspendu sans toutefois d'impact salarial.
Immédiatement, la presse s'empare de l'affaire et disserte de ce fameux coup de téléphone non professionnel à UNE employée de l'aéroport. A ce stade l'anonymat des contrôleurs est encore préservé. Le NATCA de son coté est très choqué des approximations inhabituelles du communiqué du NTSB ... il va réagir.
Réaction du NATCA pointant les incohérence du NTSB
NATCA STRONGLY DISPUTES NTSB INFERENCE OF CONTROLLER RESPONSIBILITY IN HUDSON RIVER CRASH SEQUENCE
"Air traffic controllers today are strongly disputing
misleading and – in one passage – outright false parts of Friday’s NTSB
Hudson River mid-air crash press release that mistakenly and unfairly
assign responsibilities to a Teterboro, N.J., controller during the
pre-crash sequence of events that simply did not exist.
At issue are four words in the NTSB press release that wrongly infer
that the Teterboro controller could have warned the pilot of the Piper
aircraft about the helicopter over the Hudson River that the aircraft
eventually hit. The press release infers that at the time the Teterboro
controller told the aircraft to switch his frequency to talk to Newark
Tower controllers, there were several aircraft detected by radar in the
area immediately ahead of the airplane, “including the accident
helicopter.” NATCA emphatically declares that these four words are
absolutely false and have contributed to the reckless and mistaken
conclusion that the Teterboro controller could have prevented this
crash.
The same NTSB press release clearly states that the helicopter did not
show on radar until 1152.27, seven seconds after communication with the
aircraft was switched from Teterboro to Newark at 1152.20. But the
poorly written and misleading passage about the “accident helicopter”
has left the mistaken impression that the Teterboro controller was
responsible for not warning the aircraft about that traffic.
Furthermore, and equally disturbing, the NTSB privately
revealed to NATCA officials over the weekend that it knows that the
four words in question in its press release are “misleading and
inappropriate.” A high-ranking NTSB official stated in an e-mail that
the wording “could have been clearer” but that a correction “will not
be issued.”
“We believe the NTSB is wrong to infer there was a traffic
advisory that could have been issued from Teterboro Tower to the
aircraft,” said Ray Adams, NATCA Facility Representative at Newark
Tower who is representing the Teterboro Tower controller in the NTSB
crash investigation. “The helicopter was not depicted on the radar
prior to the switch of control from Teterboro to Newark Tower.
Teterboro had no opportunity to call that traffic. The service of air
traffic control is based on "known and observed" traffic. The Teterboro
controller had neither seen nor known about the accident helicopter at
the transfer of communication to Newark.
“Also, let’s remember that the aircraft never made radio
contact with Newark, as Teterboro had requested. Nobody was talking to
him. You cannot issue traffic warnings to a pilot who is not
communicating with you. You have to reach the pilot first and the
Teterboro controller – as is accurately made clear in the NTSB press
release– tried twice, to no avail.”
Added NATCA President Patrick Forrey: “Let me make this as
clear as I can: our air traffic controller at Teterboro did his job. We
believe he is not responsible for contributing to this tragic accident
and there is nothing he could have done to prevent it from happening.
We respect the NTSB and we value our participation in NTSB
investigations. But in this case, the NTSB has completely ignored our
input, painted an unrealistic view of the job description of a
Teterboro controller and fueled a public feeding frenzy that unfairly
blames this particular Teterboro controller for not acting to stop the
sequence of events that led to the crash.
“We respectfully ask that the NTSB immediately act to stop
this rush to judgment that this controller had anything to do with the
crash until the Board’s full investigation is complete. An immediate
correction of the flawed press release would be an appropriate first
step.”"
Alors certes, le NTSB et la FAA ont convenu que le NATCA avait raison sur les faits mais l'ont éjecté de l'enquête pour avoir rompu la clause de confidentialité. Aux USA en effet, le syndicat des contrôleurs est observateur des enquêtes et à accès au dossier bien avant qu'il soit rendu public, la contrepartie est qu'il doit en respecter la confidentialité en particulier vis à vis des médias.
Visiblement d'autres sources proche de l'enquête mais qui savent rester anonymes continuent d'alimenter la presse avec des documents sensibles, l'identité des contrôleurs impliqués ainsi que des transcripts des conversations ...
Ce qui a motivé l'appel du contrôleur à l'employée de l'aéroport est apparament le fait que cette dernière avait du aller chercher un chat mort sur le tarmac d'où un échange certes peu professionnel mais néanmoins bien innocent.
La transcription qui suit est issue de la presse, elle n'y a aucune confirmation officielle.
"11:48:46 a.m. the Teterboro controller contacts a helicopter in the
area to report that a plane is taking off and "will be turning to the
southeast, join the river, climbing to 1,100 (feet)." The controller
asks the Piper, tail number N71MC, to report its altitude.
11:50:05 a.m. Piper pilot: "Climbing out of four hundred."
Teterboro controller: "Traffic 11 o'clock and two miles, northwest bound one thousand (feet), a helicopter."
Piper pilot: "Seven one mike charlie, lookin'."
At that point, the helicopter pilot reports the Piper is in sight, and the Teterboro controller tells the Piper, "helicopter has you in sight."
Piper pilot: "Thank you, sir."
11:50:41 a.m. the Teterboro controller gets on the phone with a woman from the airport's operations center. "Do we have plenty of gas for the grill?" he asks.
Operations: "Huh?"
Controller: "I said, we got plenty of gas in the grill?
Operations: "(unintelligible) it kinda sucks that we can't, we won't be able to do it today."
Controller: "(unintelligible) fire up the cat."
Operations: "Ooh, disgusting. Augh, that thing was disgusting."
Controller: "Chinese people do it, so why can't we?"
Operations: "Augh, stop it."
Controller: (laughter).
11:51:17 a.m. Controller, to the Piper pilot: "One mike charlie, start a left turn to join the Hudson River."
Piper pilot: "One mike charlie."
Controller: "This freakin' guy"
Operations: "I know (laughter).
Controller: (unintelligible)
Operations: "Oh my god, it was pretty bad. Ugh."
The conversation continues for about 2½ minutes, interspersed with radio communications with various aircraft.
11:52:19 a.m. the controller radios the Piper and instructs the pilot to contact the Newark airport tower on a certain frequency, and the pilot repeats the instruction. At about the same time, the Newark tower calls the Teterboro tower about the Piper plane.
Newark controller: "Hey, Teterboro, Newark. Would you switch that guy, maybe put him on a two-twenty heading to get away from that other traffic please?
Teterboro controller: "Say again, Newark."
Newark controller: "Can you switch that PA-32 (the Piper)?"
Teterboro controller: "I ... did keep an eye on him, though."
Newark controller: "I'm not talking to him, so..."
Teterboro controller, trying to radio the Piper: "One mike charlie, Newark is (on frequency) twenty-seven eighty-five. He's lost in the hertz, try him again."
Newark controller: "One mike charlie, Newark."
During this time, the Teterboro controller is also on the phone with the woman in the operations office.
11:53:07 a.m., Teterboro controller says to the operations office: "Damn."
Operations: "What's the matter..."
Controller: "Yeah, let me straighten stuff out." He hangs up at 11:53:10, four seconds before the collision occurs.
Teterboro controller, on the radio to Newark: "Newark, Teterboro. Did you get him yet?"
Newark controller: "Nope."
11:55:17, Newark controller: "I think he went down in the Hudson."
11:55:42, another helicopter pilot in the area: "Be advised there was an airplane crashed into a helicopter just south of the Lincoln (tunnel) a minute ago.
Teterboro operations: "Did he say what I thought he said?"
Controller: "Yeah."
Operations: "Where at?"
Controller: "Over the river."
Operations: "Oh, my lord. Okay, thanks.""
De leur coté, la FAA et le NATCA semblent revenus sur une ligne plus proche. La FAA déclare en effet que "the controller's actions were inappropriate and unacceptable, but didn't appear to have contributed to the accident." ce qui ne plait pas trop au NTSB qui rappelle que c'est à lui de déterminer quel a été le rôle de chacun dans cet accident. Le NATCA confirmant pour sa part que "This phone call and the FAA's allegations that it was inappropriate are something that will handled by the FAA in a disciplinary matter we will be involved in, but the bottom line for us is that this call had nothing to do with this tragic accident that occurred"
16 février 2009
KBUF : analyses du FDR
L’analyse des enregistreurs a permis une description des dernieres évolution avant le crash. 26s avant l’impact les alarmes de décrochage, se sont déclenchées, désengageant le pilote automatique qui était resté enclanché malgré le givrage. L’appareil a immédiatement subi un tangage sévère, de 31° vers le haut puis 45° vers le bas, ainsi qu’un important roulis, de 46° vers la gauche puis 105° vers la droite. Il aurait également perdu 800ft en cinq secondes. Il s’est écrasé à plat et, pour une raison indéterminée, dos à l’aéroport.
14 février 2009
Crash d'un Dash-8 à KBUF ... transcript released
Ca devient une habitude aux USA, les transcriptions des échanges radio entre l'ATC et le bord sont rendu public avec une vitesse stupéfiante en Europe.
Et à partir de 10:15:10 la transcription approximative (index 920 sur le lecteur ci-dessus):
10:15:10 - Colgan 3407. Three miles from Klump. Turn left heading 260 Maintain 2,300 until established localizer Cleared ILS approach Runway 23.
10:15:17 - Colgan 3407 acknowledges.
10:15:25 - ? 1998 turn right heading 140
10:15:28 - right 140,1998
10:15:44 - good evening North West 1130, 148 for 11, 11.000 at Dunkerk with S.
10:15:51 - Approach North West 1130 good evening ??? 2980 proceed final ILS approach for runway 23
10:15:58 - 2980, 23 North West 1130
10:16:02 - Colgan 3407 contact tower 120.5. Have a good night.
10:16:07 - 3407.
10:16:11 - Fedex 137 Heavy contact Cleveland center 125.2. have a good evening.
10:16:14 - Cleveland on 125.2, fedex 137 heavy.everyone.
10:16:20 - ??? 3512 descent and maintain 7000
10:17:04 - Colgan 3407. Approach.
10:17:11 - Delta 1998 ... localiser for sequencing
10:17:15- Delta 1998 Thank you
10:17:20 - Colgan 3407. Buffalo.
10:17:25 - Colgan 3407. Approach.
10:17:33 - Delta 1998 look out your right side about five miles for a Dash-8. It should be about 2,300. Do you see anything there?
10:17:41 - Negative. Delta 1998. Wherre just in the bottoms and nothing on the TCAS.
10:17:50 - Colgan 3407. Buffalo....
10:18:02 - ?? 920 ... disregard contact Approach
10:18:04 - Approach
10:18:15 - Buffalo, ??920 is 243 to 5000, 540 the heading.
10:18:25 - ??920, ... radar contact
10:18:48 - Buffalo, 920 ...
10:18:50 - ... radar contact, maintain 5000.
10:18:51 - maintain 5000, we'd like to request a continuous climb up for us.
10:19:00 - 920, continue climb, climb and maintain 8000.
10:19:04 - up 8000, we'd like to put 10000 as a final level.
10:19:08 - ??9200, climb and maintain 10000.
10:19:10 - 10000, 920 thanks.
10:19:13 - Delta 1998, turn left, left heading 360.
10:19:16 - left 360, delta 1998, you don't want us to climb at all ?
10:19:20 - .... you,sir.
10:19:30 - Delta 1998, just maintain 2300.
10:19:33 - Delta 1998, affirmative. Delta 1998, are you VFR condition here ?
10:19:36 - Negative we're IMC.
10:19:38 - Roger.
10:19:40 - Southern 254, turn left heading 050.
10:19:42 - left 050, for southern 254.
10:19:45 - Northwest 1130, turn left heading 070 descend and maintain 9000.
10:19:53 - 070, 11, 11000 for 9000, Northwest 1130.
10:20:11 - Colgan 3407. Buffalo tower. How do you hear?...
10:20:17 - .... you have frequency ?
10:20:21 - 205 contact approcach on, well just stay with me sir ...approach shortly
10:20:28 - Ground communication, you need to talk to somebody at least five miles northeast. Possibly Clarence. That area right in there. Akron area. Either state police or sheriff's department. You need to find out if anything is on the ground. This aircraft was five miles out and all of a sudden we have no response from that aircraft.
10:20:46 - All I can tell you is that an aircraft (was) over the marker and we're not talking to them now.
10:21:03 - Delta 1998. You got any icing where you're at?
10:21:06 - We picked it up on the way down, but I don't think we're building any more here. But about 6,500 down to about 3,500 maybe....
10:21:08 - Ok, thank you sir.
10:21:20 - Delta 1998, it's gonna be a delay, i'm gonna bring you back around.Expect a hold over Klump.
10:21:26 - All right, expect a hold over Klump, Delta 1998.
10:21:33 - Delta 1998, climb and maintain 4000. Turn left heading 270.
10:21:37 - climb 4000, left turn heading 270, Delta1998.
10:21:46 -Jet Blue 5 I'll have to get right back to you, sir. Apparently we have an emergency and I'll get back to you as soon as I can....
10:22:10 - Delta 1998, turn left heading 260, intercept the localizer in ... you can maintain your present altitude, just maintain 3000 till you'r established for now, have you approach ... a little closer.
10:22:19 - All right maintain 3000, joinning ILS runway 23 Delta 1998.
10:22:51 - cactus 1452, wer'e bringging you back around here shorlty, to the airport.
10:22:59 - Ok we're picking up ... ???? for one hour.
10:23:06 - Northwest 1130, turn left heading 050 ... 1130.
10:23:33 - Delta 1998, you can descent at your discretion maintain 2300.
10:23:35 - own discretion 2300, delta 1998.
10:23:52 - cactus 1452, turn right heading 140.
10:23:54 - was this for cactus 1452 ?
10:23:57 - All aircraft this frequency: We did have a Dash-8 over the marker that didn't make the airport. He appears to be about five miles away from the airport. Delta 1998, I'm gonna bring you in on the approach, if you could give me a PiRep when you get to 2300, and ah, if you have any problem with the localizer, anything let me know, however we're showing all in the green here.
10:24:23 - Wilco.
10:24:27 - cactus 1452; turn right heading 160 descent and miantain 2300.
10:24:29 - descent to 2.3, cactus 1452.
10:24:39 - ?? 405 contact ... approach 133.4
10:24:41 - 133.4 ?? 405 good night.
10:24:47 - Delta 1998 6 miles from Lump, maintain 2300 established on the localizer cleared ILS Approach Runway 23
10:24:58 - ILS 23 and we're still in the IMC here, Delta 1998.
10:25:00 - You got any kind of icing or anything there?
10:25:05 - It doesn't appear to be building. We got about a half inch, well, about a quarter inch on us from the descent that has remained with us all the time. ...
10:25:15 - Thank you, Cactus 1452, turn right heading 220, intercept the localizer.
10:25:20 - Intercept the loc for cactus 1452 and we've been picking up rime ice here for the last, oh, 10 minutes.
10:25:25 - OK Standby on the rime ice report. Southen 2512 descent and maintain 4000.
10:25:35 - As soon as you can sir ...
10:25:38 - Euh, Who was that?
10:25:42 - 52 sir. We've been getting ice ever since 20 miles south of the airport.
10:25:46 - Cactus 1452. OK. If you could, let me know when you get out of the icing. Aircraft coming up from the south wasn't reporting that earlier....
10:25:57 - Buffalo , ask direct Aligating for 920.
10:26:02 - 920, proceed ditrect to Alligating ?? , sir
10:26:05 - Direct Alligating , 920 thanks.
10:26:22 - Southern 3512, turn right heading 220, intercept the localizer.
10:26:24 - right heading 220, intreccept the localizer for Southern 2512.
10:26:28 - Delta 1998, if you could just disregard the ?? contact tower on 120.5 just let them know if you have some variation on the localizer anything.
10:26:33 - 120.5 delta 1998, thanks.
10:26:43 - North west 1130,descend and maintain 7000.
10:26:46 - leaving 9000 for 7000, Northwest 1130.
10:26:50 - Cactus 1452, 7 miles from Klump, maintain 2300 till established, clear ILS approach runway 23
10:27:00 - 2300 till establish clear ILS runway 23, cactus 1452. And the ice is starting to come off the windscreen now.
10:27:08 - Any kind of information we could get we'd appreciate.
10:27:11 - So right now at 2,300 it seems pretty clear for you.
10:27:17 - The ice is starting to dissipate.
10:27:19 - Thank you.
10:27:21 - Southern 3512. If you're picking up any ice you should be getting out of it shortly. descend and maintain 2,300
10:27:30 - And the wind around please ? wind is 260 at 14.
10:28:05 - Cactus 1452. Thanks for your help. I appreciate it. Contact tower 120.5
10:28:11 - Fine for Cactus. Did you find Colgan?
10:28:15 - Unfortunately. They said he went down about right over the marker Klump....
10:28:24 - Northwest 1130, turn left headin 350.
10:28:28 - 350, Northwest 1130.
10:28:34 - Southern 2512, 4 miles from Klump, maintain 2300 until established on the localiser clear ILS runway 23.
10:28:40 - ILS 23 for Southern 2512.
10:28:50 - Colgan say again ????
10:28:57 - ???
10:29:00 - runway ????,delta 1998
10:29:18 - Tower. Cactus 1452 is coming up on the Klump. And, uh, we saw the ground. You guys know what's going on?
10:29:24 - Cactus 1452. Buffalo tower. Winds at 2-6-0 at 1-4 runway 23 clear to land. Yes sir, we are aware.
13 février 2009
Premiere collision en vol spatiale
Puisqu'on s'ennuie ferme dans les salle de contrôle en ce moment, on pourrait peut être s'occuper de piloter les drones et de faire du Space Traffic Control ?
Deux satellites de télécommunications, l’un américain et l’autre russe, sont entrés en collision à 800km d’altitude au-dessus de la Sibérie le 9 février, c'est le premier évènement de cette nature.Les deux satellites ont été détruits. On s'est inquiété un moment que les débris ne viennent percuter la station spatiale internationale car son orbite est beaucoup plus basse (environ 400km d’altitude).
05 février 2009
Le live traffic du crash de l'Hudson released
C'est sur le site de CNN : http://www.cnn.com/2009/US/02/05/1549.voice.recorder.tape/index.html
Et pour faciliter l'écoute voici la transcription des communications : Hudson transcript
ça commence à 20h27:36 en page 3
19 janvier 2009
A320 dans l'Hudson River ... c'était prévu ! (humour !)
L'année 2009 commence très fort: première démonstration de l'efficacité d'une gestion unique du contrôle aérien et des voies navigables.
Prochaine étape, le traité FABEC prévoit la réalisation d'un prestataire intégré du transport aérien et maritime:
- Les premiers ferry prévus à CDG dès 2011
- De nouvelles perspectives professionnelles pour les basses couches
- Diversification des postes offerts aux arrêts de qualification
Et bien sûr les images de ce kiss sea-ing :
11 décembre 2008
Rapport d'accident du GOL et du Legacy au Brésil
Le BEA brésilien vient de rendre son rapport ... le contrôle aérien est clairement mis en cause de façon principale même si les pilotes du Legacy ne sont pas exempts de tout reproche.
Le rapport intégral est disponible en anglais ici !
Pour un résumé rapide :
- The Sector 5 controller initiated the handoff of N600XL to Sector 7 at an unusually early point, prior to a navigational fix at which a level change should have been assigned.
- ATC did not issue a level change instruction to N600XL at or prior to crossing Brasilia.
- The controllers at Sector 5 and Sector 7 were unaware of the status of N600XL’s altitude clearance, and did not take positive action to provide an amended clearance, confirmation, or appropriate coordination.
- The automatic change of the datablock field from “cleared altitude” to “requested altitude” without any indication to, or action by, the ATCOs, led to the misunderstanding by the Sector 7 controller about what altitude clearance was issued to N600XL.
- The collision avoidance technology aboard the aircraft did not function, likely due to inadvertant inactivation of the transponder on N600XL.
- The flight crew of N600XL did not notice the inactive status of the transponder.
- ATC did not take appropriate action in response to the loss of N600XL’s transponder.
- The automatic display of an altitude value (“3D”) which is invalid for ATC use reinforced the incorrect assumptions that N600XL was descending.
- ATC continued to apply RVSM separation standards despite a lack of mode C transponder altitude information.
- Neither ATC nor the flight crew recognized the significance of the long time period without two-way communication to N600XL.
- The flight crew of N600XL did not recognize the significance of the long time period spent at a non-standard cruise altitude for the flight direction.
- ATC did not take adequate action to timely correct a known lost communication situation with N600XL.
- Incorrect frequency utilization and ATC sector configuration within the CINDACTA contributed to the breakdown in communication with N600XL and the accident sequence of events.
- The Sector 07 controller did not inform Amazonic ACC of the lost communication and non-transponder status of N600XL.
- DECEA did not provide adequate training and supervision to develop effective skills for the ATCOs to appropriately handle this situation.
- The evidence does not fully support the conclusion that the crew of N600XL’s flight planning, or amount of time spent planning, contributed directly to the accident.
PROBABLE CAUSE
The evidence collected during this investigation strongly supports the conclusion that this accident was caused by N600XL and GLO1907 following ATC clearances which directed them to operate in opposite directions on the same airway at the same altitude resulting in a midair collision.
The loss of effective air traffic control was not the result of a single error, but of a combination of numerous individual and institutional ATC factors, which reflected systemic shortcomings in emphasis on positive air traffic control concepts.
Contributing to this accident was the undetected loss of functionality of the airborne collision avoidance system technology as a result of the inadvertent inactivation of the transponder on board N600XL.
Further contributing to the accident was inadequate communication between ATC and the N600XL flight crew.
28 novembre 2008
Crash A320 à LFMP
Un A320 immatriculé DAXLA sous plan de vol GXL888T s'est écrasé au large du Canet-Plage le 27 novembre 2008 vers 15h45 UTC. Les 7 personnes à bord ont perdu la vie.
L'appareil était en approche à LFMP lorsque l'accident est intervenu. Il rentrait d'un vol circulaire après une opération de maintenance auprès de la société EAS à Perpignan. Cet appareil était a priori en fin de location auprès de German XL et devait être repris par son propriétaire Air New Zealand.
Le PLN déposé au FL380 : ORBIL GAI SECHE MANAK DEGEX TERKU DELOG PPN LATEK GAI ORBIL
A-t-il fait le vol entier comme déposé ? On peut en douter sachant que le BEA annonce que l'accident a eu lieu après environ une heure de vol. Or il faut au moins une heure pour aller jusqu'au point le plus éloigné TERKU.
Le DAXLA dans sa livrée XL Airways
Le DAXLA dans sa livrée ANZ
Selon des radio amateurs qui écoutaient les fréquences aviation : "le contact radio avec l'approche
a eu lieu vers 16h45. il etait direct PPG en descente FL120. Il a été pris en
guidage radar car le traffic précédent, un Ryanair, etait sur la STAR.
Cap au 090, puis direct LANET, clear LANET ILS 33, descend 4000fts qnh 1016. Le
pilote a collationé et c'est la dernière fois qu'on l'a entendu. Il n'y a pas eu de Mayday."
Procédure LANET ILS 33
Lieu du crash dans le 110° de PPG pour 10,5NM
11 octobre 2008
Enquête sur le crash JKK à LEMD
L’enquête avance sur l’accident du MD82 de la Spanair. Le BEA espagnol a publié un rapport
préliminaire le 10 octobre. Il semblerait que les becs
de bord d’attaque n’étaient pas dans leur bonne position lorsque
l’appareil a décollé ...
Après analyse des boîtes noires, les enquêteurs n’ont en effet constaté aucune
anomalie au niveau des réacteurs, aussi bien en terme de poussée que
dans le comportement des reverses. L’appareil a atteint la vitesse de 147 nœuds (V1 annoncé) et 154 nœuds (Vr) deux
secondes plus tard, l’équipage ne constatant aucune défaillance lors de
la rotation ni aucune alarme.
Pourtant, l’inspection des restes du MD-82 a révélé que les becs de
bord d’attaque étaient en position rétractée. L’appareil n’a donc pu
s’élever du sol que d’une douzaine de mètres, bénéficiant de l’effet de
sol, avant de retomber faute de portance suffisante.
On ne sait pas encore pourquoi les « slats » ne se sont pas déployés
et ni pourquoi aucune alarme ne l’a signalé à l’équipage, d’autant plus que les alarmes de décrochage et le GPWS ont elles
fonctionné.
Pour les hispanophones, le rapport est ICI
